Posts filed under ‘Improvement’

“…This past year, I have achieved something big that I’ve not spoken of until now. Countless hours of physical therapy — and the talents of the medical community — have brought me new movement in my right arm. It’s fractional progress, and it took a long time, but my arm moves when I tell it to. Three years ago, I did not imagine my arm would move again. For so many days, it did not. I did exercise after exercise, day after day, until it did. I’m committed to my rehab and I’m committed to my country, and my resolution, standing with the vast majority of Americans who know we can and must be safer, is to cede no ground to those who would convince us the path is too steep, or we too weak. “

How can we not stay the course? We will continue to advocate for those who need a voice – for the long term.

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The Center for Medicare Advocacy, along with its co-counsel Vermont Legal Aid are pleased that the Settlement Agreement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved January 24, 2013 at the conclusion of a scheduled fairness hearing, marking a critical step forward for thousands of beneficiaries nationwide.

The plaintiffs joined with the named defendant, Secretary of Health and Human Services Kathleen Sebelius, in asking the federal judge to approve the settlement of the case. With only one written comment received, and no class members appearing at the fairness hearing to question the settlement, Chief Judge Christina Reiss granted the motion to approve the Settlement Agreement on the record, while retaining jurisdiction to enforce the agreement in the future, as requested by the parties.

“We are not surprised but are very pleased that the judge ruled the settlement is fair, reasonable and adequate,” said Gill Deford, Litigation Director of the Center for Medicare Advocacy. “This moment is a culmination of two years of hard work, in conjunction with partners and advocates, to ensure that those who need health services covered under the Medicare law are not denied based on an illegal, outdated rule of thumb.”

With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatients settings. CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.

“It is important to note that the Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign,” said Judith Stein, Executive Director, Center for Medicare Advocacy. “We’ve been hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard. Coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. This is the law of the land – agreed to by the federal government and approved by the federal judge. We encourage people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.”

For people needing assistance with appeals, the Center for Medicare Advocacy has self-help materials available on its website, www.medicareadvocacy.org. This information can help individuals understand proper coverage rules and learn how to contest Medicare denials for outpatient, home health, or skilled nursing facility care.

“It is exciting to know that by this time next year, Medicare policies will clearly state that coverage for skilled maintenance nursing and therapy is available, and that a beneficiary’s access to coverage does not depend on the potential for improvement, but rather on the need for skilled care,” continued Stein.

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Few people understand the value of Medicare’s home health coverage. In fact, many people who qualify for Medicare instead pay out-of-pocket, go without needed care, look to Medicaid for payment, or even enter nursing homes unnecessarily. Learn about Medicare home health coverage from nationally known beneficiary advocates. This Wednesday, September 12th!

Unknown to most people with Medicare, and contrary to what is often stated by the Centers for Medicare & Medicaid Services (CMS), the Medicare home health benefit can provide long term coverage for those who qualify. This webinar will help advocates understand the potential of this important coverage so that people with long-term and chronic conditions can obtain the nursing, therapy and home health aide care they need to remain at home. The presenters will explain:

Catching these criminals is good news for the federal government, taxpayers, and Medicare beneficiaries – such massive fraud is exactly the type of waste in Medicare that needs to stop.

However, as good as this news is for Medicare, we have to ask: how does Medicare pay out hundreds of millions in fraudulent home health claims over half a decade, while denying home health coverage for our 80-year-old client in Maine with paraplegia?

Ms. M’s doctors ordered skilled nursing for wound care and physical therapy to maintain her ability to use her wheelchair in her home. She has a legitimate need for home health services, but the only home health agency in her area claims the Medicare agency will charge it with fraud if it bills Medicare, because she won’t improve. This goes directly against the Medicare regulations, which allow for services designed to maintain her level of function. Unfortunately this “Improvement Standard” is so ingrained in Medicare contractors and providers, that providers fear being accused of fraud if they bill for these legitimate services.

We are buoyed by the successful investigation by law enforcement in the Texas case. Such victories should leave more money for people like our client, who have legitimate home health needs that are coverable by Medicare.

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Plaintiffs have overcome a major hurdle in a lawsuit filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of Medicare beneficiaries with long-term and chronic conditions. In a comprehensive 35-page decision, Chief Judge Christina Reiss refused the federal government’s request to throw out a lawsuit that seeks to end use of an illegal Improvement Standard to deny Medicare coverage. The Improvement Standard is a “rule of thumb” that Medicare uses to deny or terminate coverage to beneficiaries whose conditions are not improving. Jimmo v. Sebelius, Civil No. 5:11-CV-17 (D. VT. 10/25/20011).

“The Improvement Standard is the most unfair and harmful reason for Medicare denials,” stated Judith Stein, executive director of the Center for Medicare Advocacy. “It has a particularly devastating effect on patients with chronic conditions such as Multiple Sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease, and paralysis.”

The lawsuit, which was filed in January of this year, was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions.

In asking the court to dismiss the case, the government raised several arguments to contend that the court lacked jurisdiction over the plaintiffs’ claims. The government also argued that the plaintiffs failed to state a claim, namely, that there was no proof that the government was even applying such a policy as the Improvement Standard. Judge Reiss rejected that contention. She did agree, however, that the court lacked jurisdiction over one beneficiary plaintiff and one organizational plaintiff, but the case will go forward with the remaining eleven plaintiffs.

“This is a great first step for these plaintiffs and for Medicare beneficiaries in general,” remarked Gill Deford, the lead attorney for the plaintiffs. “The Improvement Standard has been used for over 30 years to deprive hundreds of thousands of Medicare beneficiaries of coverage they desperately needed. This decision starts the process of ending that illegal policy.”

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Instead of raising the age of eligibility for Medicare, why don’t we just use Part D as a model and create a new Eligibility Donut Hole?

People ages 65 – 69 can keep their eligibility. But, between ages 70 and 85: Into the new Donut Hole. Eligibility for Medicare would end during this time – after all it’s these older people that start getting sick, so it’s the perfect time to stop paying for their health care. The new Donut Hole would save the government a ton of money!

Those who do make it through the Eligibility Donut Hole without Medicare, would once again become eligible at age 86. At that point most people only need “comfort measures” and their conditions usually won’t improve, so Medicare wouldn’t pay for their care anyway!

If the goal is to save money, a new Medicare Eligibiity Donut Hole is the way to go.

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On January 18th, the Center for Medicare Advocacy, with co-counsel Vermont Legal Aid, filed a national class action law suit in federal district court to eliminate Medicare’s long-standing practice of denying coverage and access to care for people who are not going to improve, or improve sufficiently, or improve quickly enough.

This inappropriate “Improvement Standard” keeps people with long-term and chronic conditions from obtaining medically necessary health care and therapeutic services such as nursing, physical, occupational, and speech therapy. That is what happened to the lead plaintinff, Glenda Jimmo.

Ms. Jimmo, a 71-year-old resident of Vermont, was denied Medicare coverage for home health nursing and aide services on the grounds that she was stable despite the fact that she had diabetes, peripheral vascular disease, on-going circulatory problems, skin lesions, and is legally blind and has a below-the-knee amputation.

The lawsuit, Jimmo vs. Sebelius, No. 5:11-cv-17 (D. Vt.), was filed in Vermont federal court on behalf of five individual Medicare beneficiaries from Vermont, Connecticut, Rhode Island, and Maine, and five organizations, National Multiple Sclerosis Society, Parkinson’s Action Network, Paralyzed Veterans of America, National Committee to Preserve Social Security and Medicare, and American Academy of Physical Medicine and Rehabilitation. The federal government has 60 days to file it’s Answer to the lawsuit.

Improvement is NOT a legal standard upon which to determine eligibility for Medicare coverage. The Center for Medicare Advocacy hopes the Jimmo case will eliminate this harmful policy and practice once and for all.